Fir Counseling, LLC | SimplePractice

Fir Counseling, LLC Send Message

Who would be receiving care?

My partner and me

Someone else

Your info

First name

Last name

Phone

Name of Partner or Person Needing Services (if different from the contact listed above):

Date of Birth of Person Needing Services:

Is it okay to leave a voicemail?

Yes No

Preferred Methods of Contact:

Text Phone call Email

Reason for care

What is the reason for seeking care?

Limited to 600 characters

Services needed for:

Child (3-9 years old) Tween (10-13 years old) Adolescent (14-17 years old) Individual (18+ years old) Couple Family Spanish-Speaking Preferred

Billing & Payment

Payment Method:

How do you plan to pay?

Out of pocket Insurance Employee Assistance Program (EAP) I'm not sure yet

Name of Insurance and Subscriber (if different from the contact or client listed above):

Limited to 600 characters

Client Preferences

Preferred Appointment Days and Times:

Is there anything else you would like us to know?

For example: insurance or payment questions, clinician preference, or specialty needs such as PCIT or EMDR.

Limited to 600 characters

Therapist Preference:

Female Male Either

Preferred Therapy Location(s):

McMinnville Portland Virtual

How did you hear about us?

Crisis Line Current Client Fir Counseling Website Friend Insurance Internet Search Psychology Today Website Doctor Referral Therapist Other - please note in the box below

Other:

If you or others are in immediate danger or experiencing a medical emergency, call 911 immediately.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice.